A nurse is caring for a client who has left lower-lobe atelectasis. In which of the following positions should the nurse place the client for postural drainage?
Supine in low-Fowler's position
Side-lying with the right side of the chest elevated
Right lateral in Trendelenburg position
Prone with pillows under the lower extremities
The Correct Answer is C
a. Supine in low-Fowler's position - This position is not effective for draining the left lower lobe.
b. Side-lying with the right side of the chest elevated - This position would not effectively drain the left lower lobe.
c. Right lateral in Trendelenburg position - This is correct. Placing the client on their right side with the chest lower than the hips (Trendelenburg position) helps gravity assist in draining secretions from the left lower lobe.
d. Prone with pillows under the lower extremities - This position would not be effective for draining the left lower lobe.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Loosen the client's bed linens:
For support surfaces to be effective, there must be minimal layering in between the device and the person. A single sheet that can be kept dry and crease free is optimal. Loosening linens can help make the client more comfortable by reducing pressure and friction on the skin, but it does not directly address the client's acute pain from a pressure injury.
B. Provide bright lights in the client's room:
Bright lights may not be directly relevant to managing acute pain from a pressure injury. In fact, some clients may prefer a dimly lit environment when experiencing pain. Therefore, this option is not the most appropriate for pain management in this case.
C. Massage the client's sacrum:
Massaging the client's sacrum is not recommended when there is a pressure injury, as this could further damage the tissue and exacerbate the injury.
D. Offer to play music in the client's room:
Music therapy is a widely recognized nonpharmacological intervention for pain management. Listening to music can reduce the perception of pain by distracting the client, promoting relaxation, and triggering the release of endorphins. This approach is safe, inexpensive, and can be tailored to the client’s preferences.
Correct Answer is B
Explanation
A. Use an 18-gauge, 1-inch needle to administer the medication.An 18-gauge needle is too large for subcutaneous heparin injections, which require a smaller, finer needle, typically 25- to 27-gauge and ⅜- to ⅝-inch in length. The smaller gauge reduces discomfort and is appropriate for subcutaneous tissue.
B. Inject 5.1 cm (2 in) away from the umbilicus.Heparin injections should be given at least 2 inches from the umbilicus to avoid areas with dense blood vessels, which decreases the risk of hematoma formation and improves medication absorption.
C. Expel air bubble before injecting medication.For prefilled heparin syringes, the small air bubble should not be expelled, as it helps ensure the full dose is administered and can reduce bruising by sealing the medication in the tissue.
D. Massage the injection site after withdrawing the needle.Massaging the site after a heparin injection is not recommended as it increases the risk of bruising and tissue irritation. Instead, gentle pressure may be applied briefly if there is bleeding at the site.
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